Abstract

Background: Throughout the Eastern Mediterranean region (EMR), tobacco is used primarily in two forms: cigarette smoking and waterpipe
(called narghile (nar-GIL-eh) in Syria) smoking.

Objective: To explore whether narghile smokers are different from cigarette smokers in how their smoking habits are embedded in their
everyday lives.

Methods: One-to-one interviews with 16 adult narghile smokers and 16 adult cigarette smokers about their feelings, experiences and
beliefs regarding their initiation, use patterns, and attempts to quit.

Findings: Narghile smokers found that narghile was a pleasurable social experience embedded in cultural rituals. By contrast, cigarette
smokers saw their cigarette smoking as a mundane, oppressive, personal addiction. Narghile smokers generally started in their
20s and found that smoking narghile fostered a sense of togetherness and cultural identity, while cigarette smokers started
in their early teens, males having started to becoming a “real man”. Unlike cigarette smokers who felt stigmatised, narghile
smokers generally felt that smoking narghile was socially accepted. Cigarette smokers believed that cigarettes were harmful
to their health and harmful to those around them, but narghile smokers believed smoking narghile was relatively harmless to
themselves or to others. Unlike cigarette smokers who used cigarettes to manage stress, narghile smokers used narghile for
entertainment, leisure, and escape. However, frequent narghile smokers confessed that they felt addicted in much the same
way as cigarette smokers. Cigarette smokers and narghile smokers viewed quitting as a matter of will and conviction. Most
cigarette smokers had tried to quit. Very few narghile smokers had ever tried to quit, and most were not interested in quitting.
Disturbingly, some cigarette smokers had tried to quit cigarettes by switching to smoking narghile, but later relapsed to
smoking cigarettes.

Conclusions: This exploratory study suggests that Syrian narghile smokers are different from Syrian cigarette smokers in their perceptions
and beliefs about their smoking, and in their smoking patterns and lived experiences with tobacco. Our findings indicate that
further in-depth research is need in the EMR to understand both modes of smoking to develop effective mode-specific prevention
and cessation approaches. This study also raises concerns about a possible pattern where cigarette smokers are using narghile
as a method for quitting cigarettes, and then relapsing.

Footnotes

Funding: Supported by USPHS grants R01-TW05962, NIDA R01DA024876-01, R03-TW07233, and start-up grant (SUG) for tobacco related research
from the Initiative for Cardiovascular Health Research in the Developing Countries (IC-Health).